Joanita Nalubowa · Prevention of Future Deaths report

On 5 February 2021 the Senior Coroner, Mary Hassell, commenced an investigation into the death of Joanita Nalubowa, born in Uganda on 27th May 1990. The investigation concluded at the end of the inquest on 5 August 2024.

On 25th December 2020 Ms Nalubowa suspended herself with a ligature, whilst an inpatient at the St Pancras Hospital in King’s Cross. She was successfully resuscitated but sustained an hypoxic brain injury from which she subsequently died.

The jury returned a conclusion of Misadventure, and found as follows in Box 3:

Death by hanging ████████
████████

The medical cause of death was

1a Hypoxic ischaemic encephalopathy
1b Asphyxiation by hanging
1c Severe major depression

(1) Immediately prior to her detention the Deceased had been living in Stockton in the North of England (near Middlesbrough).

(2) However she was now divorced with few ties to that area.

(3) Moreover, importantly, concerns had been raised that the ex-partner in question was abusive.

(4) The Deceased’s family and support network was in London and not Stockton.

(5) Returning to Stockton was a source of great anxiety for the Deceased. She commented that she would “rather die than return to Middlesbrough [sic]”.

(6) It was clear to treating clinicians that securing the right accommodation was paramount to her mental health prognosis and to her future more generally.

(7) It was clear to treating clinicians that surrounding the Deceased with a positive supportive network of family was crucial in maintaining mental health.

(8) Despite all of the above, the existing framework/rules were such that all London boroughs, correctly applying the relevant criteria, rejected the Deceased’s applications for accommodation in London.

(9) The witness evidence was clear that there was no “discretion” and that London Boroughs and treating clinicians alike were powerless. The Deceased was therefore discharged to Stockton, against her wishes, against medical advice, away from her support network, and to an area where she would have to at best face her demons and at worst be in physical danger.

(10) Shortly after being told she was being discharged to Stockton, the Deceased suspended herself using a ligature.

Please see Box 4, above.

The evidence at the Inquest was that this situation is not uncommon, with those detained under the MHA not infrequently having social circumstances such that their historical place of residency is, for whatever reason, deeply inappropriate (or even dangerous).

It should be noted that section 117 Mental Health Act 1983 did not apply.

I am concerned that the rigidity and lack of flexibility in the criteria, coupled with the evidence this is a not uncommon phenomenon, gives rise to a risk of future deaths in cases which do not meet the threshold for aftercare under s.117.

Consideration should be given to giving decision makers greater latitude / discretion or the power to apply common sense, in circumstances where (a) it is foreseeable that rigid adherence to criteria will lead to personal injury (including psychiatric injury) and/or serious emotional harm (b) there is an obvious alternative solution, such as accommodation near family.